Chapter 10 Popular Itineraries Africa & the Middle East
South Africa is “a world in one country.” Diverse geography (ranging from lush subtropical regions, old hardwood forests, and sweeping Highveld vistas to the deep desert of the Kalahari) and large animals (found throughout South Africa and in protected, expansive game reserves) are one part of this world. The people who live here (with their origins in Africa, Europe, India, and Southeast Asia) make up another; they bring a vibrant, global cultural, artistic, and culinary variety to the country. All this, combined with access to the conveniences of a developed infrastructure amid the challenges of Africa, make the country truly unique.
South Africa has experienced a surge in both business and pleasure travel in the past 2 decades, with visitors arriving from within the African continent and from Europe and North America. Business travelers typically head to the commercial centers of Johannesburg, Cape Town, and Durban.
Tourist itineraries are as diverse as the country itself. From Cape Town, for example, visitors can follow the wine route of the Western Cape exploring the many wineries along the way. Or they can take spectacular drives along the coast; going east, travelers can visit the southernmost point of Africa at Cape Agulhas—where the Indian and Atlantic Oceans meet in a roar of foam—continuing on to the small scenic towns of Knysna and Plettenberg Bay. Mpumalanga, home to half of Kruger National Park, has old gold-mining towns, many of which are in near-original condition.
Game reserves located throughout the country attract many tourists. The largest, Kruger National Park, is located along the Mozambique border in the northeast (see Map 10-03). Kwa-Zulu Natal has a number of game parks (Hluhluwe-Umfolozi and Saint Lucia) set inland from Durban, and the Eastern Cape has parks (Addo Elephant Park and Shamwari) easily accessed from Port Elizabeth on the southern coast. Many smaller luxury reserves have emerged that cater to high-end travelers.
South Africa is also a common destination for humanitarian workers, missionaries, and students. A sizable number of South Africans live outside the country; those returning home for a visit are considered VFR travelers (see Chapter 9, Visiting Friends & Relatives: VFR Travel).
While there is a wide range of living standards in South Africa, most visitors experience standards comparable to those in developed countries. A smaller number of visitors may go to less developed areas, either to rural areas or to lower-income townships found outside most towns and cities. Hikers, adventure-seekers, and missionaries will experience a wider range of living standards. Similarly, the quality and availability of health care is variable. Middle- and upper-income South Africans live in low-risk environments, have a standard of health comparable to that of North Americans, and can access world-class medical facilities. Poorer South Africans live in areas with few amenities, are exposed to a wide range of diseases, and have limited access to adequate health care.
Map 10-03. South Africa destination map
All travelers to South Africa should be up-to-date with their routine vaccinations. Infectious diseases such as measles and mumps are endemic to the region. In addition, hepatitis A vaccine is recommended for most travelers, and hepatitis B vaccine is recommended for travelers who may be exposed to blood or other body fluids, including through sexual contact. Travelers should also consider typhoid vaccine, especially more adventuresome eaters or those staying in less-than-sanitary surroundings.
YELLOW FEVER VACCINE REQUIREMENTS
South Africa requires a valid International Certificate of Vaccination or Prophylaxis (ICVP) documenting yellow fever vaccination ≥10 days before arrival in South Africa for all travelers aged ≥1 year traveling from or transiting for >12 hours through the airport of a country with risk of yellow fever virus transmission. South Africa considers a one-time dose of yellow fever vaccine (properly documented with an ICVP) to be good for the life of the traveler. Any traveler not meeting this requirement can be refused entry to South Africa or quarantined for up to 6 days. Travelers may also be vaccinated on entry. Unvaccinated travelers presenting a medical waiver signed by a licensed health care provider are generally allowed entry.
Travelers going to or transiting through South Africa are advised to seek the most current information by consulting the CDC Travelers’ Health website (www.cdc.gov/travel), the website of the US embassy and consulates in South Africa (https://za.usembassy.gov/), and the embassy of South Africa in Washington, DC (www.saembassy.org/).
HIV and Sexually Transmitted Infections
South Africa has the largest estimated number of people living with HIV of any country in the world. The prevalence of HIV infection is approximately 19% among people aged 15–49 years, and the prevalence among sex workers is even higher. Other sexually transmitted infections (STIs) are also present at high rates in this population. Travelers should be aware of STI risks and use condoms when having sex with someone whose HIV or STI status is unknown.
Chloroquine-resistant Plasmodium falciparum malaria is found along the border with Zimbabwe and Mozambique in the following locations: 1) the Vembe and Mopane district municipalities of Limpopo Province; 2) Ehlanzeni district municipality in Mpumalanga Province; and 3) Umkhanyakude in KwaZulu-Natal Province. This region includes Kruger National Park (see Map 10-03). In addition, in March 2017, the CDC received reports of malaria in the western Waterberg District of Limpopo Province, an area not known previously to have malaria transmission. Visitors to all of these areas should take malaria chemoprophylaxis and use mosquito precautions; preventing mosquito bites is the first line of defense against malaria. The South African Department of Health recommends malaria chemoprophylaxis for travelers visiting malaria risk areas from September through May and reliance on mosquito-avoidance measures for the rest of the year. CDC, however, recommends chemoprophylaxis at all times of the year (see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country).
Rickettsial tick-bite fever is common in South Africa (see Chapter 4, Rickettsial Diseases). The incidence rate for visitors from Europe is estimated to be 4%–5%. The disease is characterized by an eschar at the bite site, regional adenopathy, and a maculopapular or petechial rash. Hikers and campers in rural areas are especially at risk and should take measures to prevent tick bites (see Chapter 3, Mosquitoes, Ticks & Other Arthropods). Travelers taking doxycycline for malaria chemoprophylaxis may have some protection against tick-bite fever, but no studies exist to support or refute this viewpoint. Taking doxycycline solely as prophylaxis for tick-bite fever (as opposed to taking it for malaria chemoprophylaxis) is not recommended.
As with most destinations, the risk of travelers’ diarrhea depends on style of travel and food choices (see Chapter 2, Food & Water Precautions, and Travelers’ Diarrhea). Consider dispensing a fluoroquinolone, such as ciprofloxacin, for travelers to use as self-treatment of moderate to severe diarrhea.
Schistosoma spp., parasites found throughout Africa, may be present in any body of unchlorinated, fresh water (see Chapter 4, Schistosomiasis). Travelers should avoid swimming in lakes, streams, and ponds.
Although most travelers avoid wild animals in game reserves, rabies is common in dogs and other mammals throughout the country. The KwaZulu-Natal Province has the highest incidence of rabies. Travelers have no way of telling if a given animal is rabid and should avoid all contact with animals. Instruct travelers to wash any bite or scratch from an animal with soap and water immediately and to see a clinician as soon as possible (see Chapter 3, Animal Bites & Stings, and Chapter 4, Rabies).
Hospitals in South Africa are equipped to provide postexposure prophylaxis and medical care for rabies exposures. Rabies vaccine is available throughout South Africa, and rabies immune globulin (RIG) is available in major urban medical centers. Most of the new formulations of Equine RIG used in the public health system are potent, highly purified, and safe. Private medical centers stock human RIG.
SAFETY AND SECURITY
Over the past several years, South Africa has experienced a rise in violent crime, including armed robberies, carjackings, home invasions, and rape (see Chapter 3, Safety & Security Overseas). Most incidents occur in lower-income residential areas and, as such, most visitors will not be targets or victims. However, awareness of personal safety and security should be stressed to all visitors. Travelers should rely on local guidance about what security precautions to take in specific areas.
Although South Africa has a modern road system, drivers should be alert for dangerous driving practices, stray animals, and poor roads in remote rural areas (see Chapter 8, Road & Traffic Safety).
- Blumberg LH, de Frey A, Frean J, Mendelson M. The 2010 FIFA World Cup: communicable disease risks and advice for visitors to South Africa. J Travel Med. 2010 May–Jun;17(3):150–2.
- Durrheim DN, Braack LE, Waner S, Gammon S. Risk of malaria in visitors to the Kruger National Park, South Africa. J Travel Med. 1998 Dec;5(4):173–7.
- Frean J, Blumberg L, Ogunbanjo GA. Tick bite fever in South Africa. SA Fam Pract. 2008 Mar–Apr;50(2):33–5.
- Maharaj R, Raman J, Morris N, Moonasar D, Durrheim DN, Seocharan I, et al. Epidemiology of malaria in South Africa: from control to elimination. S Afr Med J. 2013 Oct;103(10 Pt2):779–83.
- Probst C, Parry CD, Rehm J. Socio-economic differences in HIV/AIDS mortality in South Africa. Trop Med Int Health. 2016 Jul;21(7):846–55.
- South African National Travel Health Network. SaNTHNet [homepage on the Internet]. Dunvegan (South Africa): South African National Travel Health Network; 2013 [cited 2018 Sep 23]. Available from: www.santhnet.co.za/.